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Medications are also essential for clients who are simply too rattled to concentrate on therapy. I learned this lesson from an elderly client--feisty, articulate and humorous--who looked me in the eye and said, "Now, Doc, just wait a minute. I believe I'm about to die of a heart attack at worst, or that I'm going crazy at best or probably both. And you want me to sit in a chair and take deep breaths! First, get me something to calm down, and then maybe I'll try it." This client visited his primary care physician, who started him on an appropriate medication. Within three months, he was calm enough to learn breathing, relaxation and self-talk. Within a year, he was tapering off medications, attending a yoga class, meditating daily and heading into a new spiritual phase of his life.

As this case illustrates, cognitive-behavioral therapy, often in conjunction with medications, can produce remarkable results. It is often the only psychotherapy that my clients need. Often, but not always.

Getting to Deeper Issues

In many clients, anxiety obscures deeper issues. It is not uncommon for these people to complete a brief, successful course of therapy for panic attacks and then return a year or two later with related problems. Usually they have become aware of something behind their anxiety, something that drives and intensifies it. Often the problem was present during the earlier therapy, but the client was not ready to deal with it. For example, it is relatively common during the cognitive-behavioral therapy for clients to describe their spouses as supportive, kind and gentle. Upon returning to therapy, however, clients frequently reveal that there have been years of infidelity, domestic violence, financial irresponsibility or a simple lack of support. What was first presented as a fine relationship is now seen as inadequate at best.

But a person who is frequently in the grip of panic is too vulnerable, and feeling too crazy, to confront relationship problems. A woman who can't leave her house without experiencing acute anxiety is unlikely to consider a divorce, no matter how violent her husband becomes. Not until her symptoms are under control will she find the strength to confront the other problems in her life. Clients who return for additional therapy often say things like: "Well, Graham, I'm back and I can't breathe this one away. I faced the panics and now I have to face him."